Professional Documents
Culture Documents
Case studies in
Hypertension
+ Learning Objectives
Classify blood pressure according to current hypertension
guidelines, and discuss the correlation between blood pressure
and risk for cardiovascular morbidity and mortality.
Chief Complaint
“I’m here to see my new doctor for a
checkup. I’m just getting over a cold.
Overall, I’m feeling fine, except for
occasional headaches and some
dizziness in the morning. My other
doctor prescribed a low-salt diet for me,
but I don’t like it!”
+ History of present illness
James Frank is a 64-year-old African-American
man who presents to his new family medicine
physician for evaluation and follow-up of his
medical problems. He generally has no
complaints, except for occasional mild headaches
and some dizziness after he takes his morning
medications. He states that he is dissatisfied with
being placed on a low-sodium diet by his former
primary care physician.
+ Past medical history
Hypertension (HTN) × 14 years
Gout
Family history
Father died of acute MI at age 73. Mother died of lung
cancer at age 65. Father had HTN and dyslipidemia. Mother
had HTN and diabetes mellitus.
+ Social History
Former smoker (quit 6 years ago; 35 pack-year history);
reports moderate amount of alcohol intake. He admits
he has been non adherent to his low-sodium diet
(states, “I eat whatever I want”). He does not exercise
regularly and is limited somewhat functionally by his
COPD. He is retired and lives alone.
+ Medications
Triamterene/hydrochlorothiazide 37.5 mg/25 mg po Q am
Doxazosin 2 mg po Q am (BPH)
Vital sign
BP162/90 mm Hg (sitting; repeat 164/92 mm Hg),
HR 76 bpm (regular), Respiratory rate 16/min, T
37°C; Wt 95 kg, Ht 6′2″
Lungs
Lung fields clear of Auscultation bilaterally. Few
basilar crackles, mild expiratory wheezing.
Heart
Regular rate and rhythm; normal S1 and S2. No S3 or S4.
Abdomen
Soft,
NTND; no masses, bruits, or organomegaly.
Normal Bowel sounds.
+ Genit/Rect
Enlarged prostate
Ext
No CCE; no apparent joint swelling or signs of tophi
Neuro
No gross motor-sensory deficits present. CN II–XII
intact. A & O × 3. alert and oriented to place , time
and person.
+ Labs
+
Urine Analysis
Yellow, clear, SG 1.007, pH 5.5, (+) protein, (−) glucose,
(−) ketones, (−) bilirubin, (−) blood, (−) nitrite, RBC 0/hpf,
WBC 1–2/hpf, neg bacteria, 1–5 epithelial cells
Electrocardiogram
Normal sinus rhythm
Clinical Pearls
The risk of hemorrhagic stroke may be increased by the use
of aspirin therapy in patients with uncontrolled HTN (e.g., BP
>150/90 mm Hg).
The majority of hypertensive patients will require two or more
blood pressuring–lowering medications to achieve
recommended blood pressure goals.
+ Questions
His
serum creatinine is high 2.2mg/dl and
normal range for male is (0.7-1.3mg/dl).
He has proteinuria.
His BP is uncontrolled.
+ Questions
Problem Identification
1.a. Create a list of this patient’s drug-related
problems, including any medications that may
be contributing to his uncontrolled HTN.
• Drug Adverse effect:
Elderly 64yrs, HTN, DM-type 2 and African American in this case ACE inhibitors or
ARBs are more efficient. (The drug of choice).
The patient must be aware that ACE-I cause cough and angioedema. If cough is
severe we can switch to ARBs and if Angioedema occur then ACE-I will become
contraindicated and must use ARBs.
The patient must be aware that Doxazosin causes dizziness, so we can advice the
patient to take the drug at night to avoid this.
It’s important to take the drug on time and within the appropriate dose especially
diuretics at morning to avoid nocturia.
Thiazide make the skin more sensetive so the use of sun block is important.
+